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Archive for May, 2007

By now you’ve heard of the Atlanta attorney who, despite knowing he was positive for tuberculosis, hopped on a commercial flight to Europe. Then, after learning he had a particularly nasty form of the infection, hopped a commercial flight back to the U.S.; as the CDC says it, he took the flight against their instructions.

Dr. Martin S. Cetron, [a CDC official,] said he reached the man on his cellphone while he was in Italy to inform him that tests performed before he left for Europe showed that he had a form of tuberculosis that was extremely resistant to standard antibiotics. Dr. Cetron said that he advised the man not to take commercial flights home from Europe and that a United States Embassy would provide assistance, including examination by a tuberculosis expert.

While the agency began to explore ways to bring the man home, he flew to Montreal and drove into the United States. Then, after agency officials made contact with him, he followed their instructions to drive safely into New York without risk to the public.

The news story is understandable and necessary. Despite the “low” risk of him having infected others on the flight, public health officials are looking for those he was in contact with. They need to spread the word, and the media is the best way to do that. But the continual coverage afforded this story is an example of the oft criticized ‘state of fear’ reporting which drives a whole host of science stories (public health stories, global warming studies, etc.)

Welcome to Grand Rounds Volume 3, Number 36. Before we jump into it, for those Americans visiting (or anyone with such an inclination): no matter how you honored the fallen yesterday, no matter your politics, please take another moment to remember those who have made the ultimate sacrifice.

It has been a real honor to put together Grand Rounds this week. There were, as usual, a ton of great submissions.

In the debate over whether to filter Grand Rounds, I stand on the populist side. I think I’ve included everything that was submitted. Even the submissions that ended up in my spam box. Hopefully, despite that, it isn’t terribly verbose.

We’ve passed the fourth anniversary of Amy’s diagnosis with diabetes. She details how you know you’ve reached a milestone when you start dreaming about diabetes. In case somehow you don’t know, she is writing over at Diabetes Mine.

What is wrong with the title Chronic Babe? Nothing says Jenni, who very nicely defends her decision to take a negative term associated with her disease – chronic – and redefine it as something positive for herself.

Off the discussion of contraception being guaranteed, and onto a discussion of pooled funding for medical care in pregnancy. Louise, writing on Colorado
Health Insurance Insiderargues for guaranteed maternity care coverage through pooled insurance company resources.

Med Journal Watch wonders why we’re wasting fish oil on dairy cows when a study says it doesn’t improve their milk prediction.
Wow. You made it all the way through. I’m proud of you. It has been great putting this together this week…largely because it was a distraction from studying.

It is hard to give Dr. Genes enough credit for the work he puts into making Grand Rounds run every single week. It really is incredible.

Next week Grand Rounds will be over at Inside Surgery (who had a very good clinical submission this week, which you should go read).

Eleven-year-old Noah Maxinâ€™s funeral is today after losing his struggle with leukemia, a fight that included the court battle his parents won for the right to decide how to treat their sonâ€™s disease.

In 2002, doctors diagnosed Noah with acute lymphoblastic leukemia. Abnormal white blood cells were gathering in his bone marrow, crowding out red blood cells, platelets and healthy white cells and leaving him at risk of infection, anemia and bleeding.

Noah began a treatment plan that included a blood transfusion, drugs and other measures. The cancer went into remission.

Noahâ€™s parents stopped the chemotherapy three months into a 31â„2-year plan favored by doctors at Akron Childrenâ€™s Hospital. The Maxins said they were concerned about the long-term effects of chemotherapy and wanted to treat Noah with a holistic approach that emphasized improved diet and strengthening the bodyâ€™s immune system. Another doctor took over his care.

Being the way in general with leukemias and lymphomas, ALL is a really heterogeneous disease. As such, we don’t know a whole lot about what Noah Maxin was facing. What was his circulating blast count a week out? What about blast % in his marrow after a week in remission induction therapy? After two weeks? What about minimal residual disease? Good prognostic measurements. What was the cell line and the cytogenetics or possible chromosomal abnormalities? Even if we did we wouldn’t be able to say whether he would’ve survived (longer) with a traditional therapy plan.

On top of that, personally I know even less. All that laid out though, I still think Noah’s death is made a little bit more tragic by the positive signs in the story. At 6 or 7 Noah was in a pretty good age range to get ALL (if he had to). As an independent factor Noah’s age probably heralded a chance for 5 year survival greater than 80%.

As the story makes it sound the numbers associated with the ‘remission’ of Noah’s leukemia were good enough to encourage his parent’s to abandon chemo. And he apparently achieved that remission within the first round of remission induction therapy.

Noah’s parents feared the side effects of the chemotherapy. Long term consequences of acute lymphoblastic leukemia treatment, including secondary malignancies, are decreasing as therapy regimens improve, but they’re still a major concern:

Recent improvements in treatment have clearly reduced the risk of adverse sequelae in children with ALL who have completed treatment. In contrast to the cumulative risk of approximately 25% at 5 years among patients treated in the early treatment era at our center or elsewhere only 14% of patients developed any adverse event at 5 years (17% at 10 years) in this large cohort receiving treatment in the modern era.

But while that explains their actions, it is far from excusing them. The question of course is, should his parents have been allowed to move him onto such unconventional treatment?

[From the Canton Repository:] In his seven-page opinion, Stucki wrote: “The court declines to venture a medical opinion on the efficacy of the chosen treatment. These are not parents who refused medical treatment or who elected to take Noah to a witch doctor or shaman or (chose) some other method of treatment which is not recognized by the medical community as legitimate.”

[Orac's Response:] I don’t know exactly what sort of woo Noah’s parents chose for him, but I would argue that using naturopathy against cancer is not all that different in efficacy from the treatments that a shaman or witch doctor would provide. In any case, even though Noah was off his chemotherapy for only four months, his tumor returned. By the time his parents turned back to conventional medicine, it was apparently too late.

The choice made for Noah by his parents was almost certainly a death sentence. Untreated, even after induction achieved remission, Noah’s leukemia was going to be fatal, wasn’t it? And whatever holistic plan his parent’s jumped on was no different than forgoing treatment altogether or as Orac says, going to a witch doctor or shaman.

Indonesia – one of the countries most affected by the avian influenza outbreak – only recently began sharing its latest strain samples again, having blocked them since December.

It had argued that the pharmaceutical companies would use the samples to produce a commercial vaccine that was beyond the country’s economic reach.

I mean, I’m all for poorer nations playing hard ball to better their footing in the world economy. There’s no doubt some of the third world’s troubles are based on exploitation by the west.

But we’re not talking about loan repayments here or a trade agreement.

True, I think the media coverage of avian flu was overblown, and created an unnecessary level of fear initially. But this is still a major worldwide public health concern.

But WHO Director-General Dr Margaret Chan has accused countries that refused to provide timely samples of crippling the fight against a possible flu pandemic.

Holding progress on a vaccine partially hostage because you want to make sure your people get a piece of it…is selfish. End of story. It literally is saying: we’re afraid we won’t benefit, so everyone will suffer. At least they’ve accepted whatever guarantees they got about the vaccine and have come around.

Each spring, the advocacy group Medical Students for Choice brings several hundred students â€” nearly 90% of them women â€” to a weekend convention to nudge them into considering abortion work. One of the most effective tools: introducing them to veteran providers.

[Y]oung doctors-in-training have found their own motivation to enter a field that they know will put them at risk of isolation, harassment and hatred. For them, doing abortions is an act of defiance â€” a way of pushing back against mounting restrictions on a right they’ve taken for granted all their lives.

“It’s like when your big brother says you can’t do something,” [Fourth Year Megan] Lederer said. “That just makes you want to do it even more.”

Abortion is one of the most common surgical procedures in the U.S., terminating about one in four pregnancies, not counting miscarriages. Yet the number of providers has fallen steadily for decades, dropping 37% between 1982 and 2000, the last year a census was taken. (During the same period, the number of abortions fell 17%.)

Coming to terms with doing this as part of your practice must be…tough…

Lederer does not know how she will handle such emotion; the closest she’s come to performing an abortion was suctioning the seeds out of a papaya to learn a first-trimester technique. She may, in the end, restrict her practice to early abortions. But that’s not an easy solution to accept. She can’t see how she could ever justify taking one woman as a patient while turning away another because her pregnancy is a few weeks more advanced.

She also knows that the few doctors who perform late second- and third-trimester abortions are mostly in their 60s or 70s. “Who’s going to do this when they leave? Someone has to,” Lederer said. “I feel in my heart of hearts that it’s the right thing to do.”

Even I – in just the short steps I’ve taken towards joining the physician fraternity – have grown a bit cynical to some patients’ complaints. But this is an utter reminder of how much respect doctors need to treat each and every complaint. Even if some patients make such difficult.

How [Edith] Rodriguez came to die at a public hospital, without help from the many people around her, is now the subject of much public hand-wringing. The county chief administrative office has launched an investigation, as has the Sheriff’s Department homicide division and state and federal health regulators.

The triage nurse involved has resigned, and the emergency room supervisor has been reassigned. Additional disciplinary actions could come this week.

Having recently been seen in the ER, Miss Rodriguez was found wallowing on the ground outside the hospital and taken back to the ER by the police.

“Thanks a lot, officers,” an emergency room nurse told Los Angeles County police who brought in Rodriguez early May 9 after finding her in front of the Willowbrook hospital yelling for help. “This is her third time here.”

The 43-year-old mother of three had been released from the emergency room hours earlier, her third visit in three days for abdominal pain. She’d been given prescription medication and a doctor’s appointment.

Turning to Rodriguez, the nurse said, “You have already been seen, and there is nothing we can do,” according to a report by the county office of public safety, which provides security at the hospital.

She falls out of her wheel chair in the waiting room where the police leave her, and writhes around on the floor without any help. Finally, her boyfriend shows up, and starts trying to find assistance for her.

Jose Prado, returned to the hospital after an errand and saw her on the floor, he alerted nurses and then called 911.

According to Sheriff’s Capt. Ray Peavy, the dispatcher said, “Look, sir, it indicates you’re already in a hospital setting. We cannot send emergency equipment out there to take you to a hospital you’re already at.”

Prado then knocked on the door of the county police, near the emergency room, and said, “My girlfriend needs help and they don’t want to help her,” according to the police report. A sergeant told him to consult the medical staff, the report said. Minutes later, Prado came back to the sergeant and said, “They don’t want to help her.” Again, he was told to see the medical staff.

Finally, the presumably annoyed police, run her name and find she has an outstanding warrant. They arrest her as she iscurled up on the linoleum floor of the waiting room. By the time they get her out to the police car she has no pulse.

The sad thing about trans fats being dictated out of New York City is that no one probably cares. Whatever outrage there is, is ageless, and is certainly not addressed in this interview with Dr. Thomas Frieden – who can only muster that it is no different than the government cleaning up the water supply.

But, in reality it doesn’t rise to the government’s responsibility for the water supply at all, does it?

While there’s still some questions out there about specific trans fats and the risks of heart disease the amount of congruency between the studies, in terms of TFAs contribution to coronary heart disease, is pretty impressive. But that is beyond the point. The level of the scientific acceptance of the fact alone shouldn’t determine public policy. As with all choices in life we need to weigh the consequences. Which include trying to quantify TFAs health impact.

Trying to quantify the contribution of trans fat to heart disease is difficult in some ways.

Relative Risk Of Coronary Heart Disease With 2% Trans Fat Diet

Supposedly low estimates contribute more than 30,000 American deaths a year to a diet with 2% of its calories coming from trans fatty acid. And that is only the contribution to deaths related to heart disease.

But while 30,000 is a shocking figure – and admitting the number may be much higher – it needs to be put into perspective.

While the gut reaction is to sit there and claim a huge distinction between denying people something which is bad for them and forcing them onto a treadmill, philosophically is it really that much of a stretch?

Doctors wanted to invoke a state law allowing the hospital to stop life support after a 10-day notice for patients deemed medically futile.

Emilio’s mother, Catarina Gonzales, said she knew her son would die but wanted doctors to continue care, pointing out that he smiled and turned his head when he heard voices. Her lawyer argued the state law was unconstitutional. In April, a judge agreed to temporarily block the hospital’s move to end life support.

“We mourn the death of Emilio Gonzales,” Michael Regier, senior vice president of legal services for the Seton Family of Hospitals, said in a statement. “We pray that in the days and weeks to come, Emilio’s mother and family will be comforted by God’s loving presence and by the knowledge that Emilio’s earthly suffering is now ended.”

The ongoing hustle prompted the Texas Senate to recently pass a law expanding the time a hospital must give a family to find another care facility to continue the futile care. The law, if it squeezes through the House before the end of this session, would expand the time from 10 days to 48 days.

This is a tough issue. I’m very close to pediatric intensivists who sincerely, utterly believe that continuing the suffering of a child who will not get better through artificial respiration goes against the Hippocratic Oath and is immoral. There is certainly an argument, under such reasoning, that allowing the family to even look into other options of continuing the suffering of their family member is immoral.

I don’t know what the answer is. I will say I’m offended by any generalized contentions about the ulterior motives of health care providers in these cases. There is huge sincerity, amongst all physicians I know, in trying to do what they think is right for their patient in these cases. Even if such puts enormous, unimaginable stress on the families.